NCC221198_FRO Submitted_20220329

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place NIA in the blank.)
Part A. Grand Palms
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Supply
Highway/Street Sunset Harbor Rd. SE Latitude 33.966 Longitude-78•218
3. Approximate date land -disturbing activity will commence:3/18/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12.63
6. Amount of fee enclosed: $ . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Donald Aiken E-mail Address [e-mail]
Telephone Cell # 910-508-0017 Fax #
V
Landowner(s) of Record (attach accompanied page to list additional owners):
D.R. Horton, Inc. 910-515-9561
Name Telephone Fax Number
131 Racine Dr., Suite 201 131 Racine Dr., Suite 201
Current Mailing Address
Wilmington NC 28403
City
10. Deed Book No. 4809
State
Current Street Address
Wilmington NC 28403
Zip City State Zip
Page No. 749 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
D.R. Horton, Inc. [e-mail]
Name
131 Racine Dr., Suite 201
Current Mailing Address
Wilmington NC 28403
City State
Telephone [phone]
Zip
t-man Haaress
131 Racine Dr., Suite 201
Current Street Address
Wilmington NC 28403
City State Zip
Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
E-mall Address
Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Elizabeth Shelton [e-mail]
Name of Registered Agent E-mail Address
131 Racine Dr., Suite 201
Current Mailing Address
Wilmington NC 28403
City State Zip
Telephone [phone]
131 Racine Dr., Suite 201
Current Street Address
Wilmington NC 28403
City state Zip
Fax Numb
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Donald Aiken
Type ornrin' ne
Sig
Assistant Secretary
Title or Authority
3/3/2022
Date
I, l� R, I Q5 a Notary Public of the County of - 66S5 d
State of North Carolina, hereby certify that appeared
personally before me this day and being duly swom acknowledged that the above form was
executed by him.
Witness my hand and notarial seal,.this day of Mµr� , 2Q�L I-
_
Seal Notary aft
pA k
My commission expires